NPIMap

Organization Active NPI

Children'S International, LLC

  • Primary Care Clinic/Center
  • Gulfport, MS
National Provider Identifier
1023549219
Registry record updated Mar 21, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
CHILDREN'S INTERNATIONAL, LLC
Practice address
15465 Oak LN
Gulfport, MS 39503-2663
Phone
(228) 831-8800
Fax
(228) 831-8020
NPI assigned
Mar 21, 2017
Organization subpart
No

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Facilities with the same owner 7

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
25D2091148Children'S International Medical Group11240 Hwy 49 #C, Gulfport, MS 39503Certificate of waiverFeb 5, 2027

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200311000634 MS Part A Provider - Rural Health Clinic 1254633308 Practice locations: Gulfport, MS

Rural health clinic certification: CCN 258964

Legal name
CHILDREN'S INTERNATIONAL, LLC
Doing business as
CHILDREN'S INTERNATIONAL MEDICAL GROUP
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 4, 2020
Last certification
May 4, 2020
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
Apr 13, 1993
Enrollment address
11240 Hwy 49
Unit 300-C
Gulfport, MS 39503-4151

All disclosed owners & managing parties 5

Medicare enrollment files

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Eduardo J Hernandez Individual 5% Or Greater Direct Ownership Interest Jan 20, 2010 50%
Corporate OfficerManager of Living Trust Jan 20, 2010 50%
Corporate DirectorManager of Living Trust Jan 20, 2020 50%
Lacey Shaw Individual W-2 Managing EmployeeArea Operations Director Jul 6, 2010
Brittany Frost Individual W-2 Managing EmployeeChief Business Officer Aug 1, 2009
The Living Trust of Eduardo and Heidi Hernandez Organization, Slidell, LA 5% Or Greater Direct Ownership Interest Sep 5, 2013 100%
Heidi B Hernandez Individual 5% Or Greater Indirect Ownership Interest Jan 20, 2010 50%
Operational/Managerial ControlLLC Manager Jan 20, 2010 50%

All facility ownership & control disclosures 3

Medicare enrollment files

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Children'S International Medical GroupFranklinton, LA, CCN 193918 Rural health clinic Operational/Managerial Control (100%) Nov 27, 2013
Children'S International Medical GroupAmite, LA, CCN 193919 Rural health clinic Operational/Managerial Control (100%) Nov 27, 2013
Children'S International Medical GroupPicayune, MS, CCN 253928 Rural health clinic Operational/Managerial Control (100%) Nov 27, 2013

National Provider Directory

National Provider Directory
Tax ID family
Children'S International LLC27 organizations share this tax ID, including this one

Other organizations with this tax ID 26

Organizations that report the same tax identification number in the National Provider Directory.

View all 26

NPPES NPI Registry

Updated by the provider on Mar 21, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Eduardo Hernandez
Title
Chief Executive Officer
Phone
(985) 646-1580

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X Primary

Addresses

Primary practice location

15465 Oak LN
Gulfport, MS 39503-2663

Mailing address

59101 Amber St
Slidell, LA 70461-3708
Phone (985) 646-1580

NPI Registry JSON

The complete record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1490054400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1490054400000",
    "number": "1023549219",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "59101 AMBER ST",
            "city": "SLIDELL",
            "state": "LA",
            "postal_code": "704613708",
            "telephone_number": "985-646-1580",
            "fax_number": "985-646-1579"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15465 OAK LN",
            "city": "GULFPORT",
            "state": "MS",
            "postal_code": "395032663",
            "telephone_number": "228-831-8800",
            "fax_number": "228-831-8020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHILDREN'S INTERNATIONAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-03-21",
        "last_updated": "2017-03-21",
        "status": "A",
        "authorized_official_last_name": "HERNANDEZ",
        "authorized_official_first_name": "EDUARDO",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "985-646-1580"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Gulfport, MS

Sources for this page

Verify at the official NPI Registry.